But today, Americans with HIV and AIDS are part of another growing epidemic -- obesity. As an HIV Nutrition Specialist working at New York's Gay Men's Health Crisis, I deal with weight issues and HIV/AIDS daily. I increasingly see clients with both HIV/AIDS and obesity -- so much so that GMHC has recently added a weight-loss clinic to its Nutrition & Wellness Program. We are in a new era, when people are living with AIDS longer. With this, obesity is occurring in people with HIV, and it is on the rise. This is becoming obvious to me and to my colleagues who work directly with clients at GMHC and other AIDS service organizations. Except among nutritionists, though, obesity seems to be a well-kept secret in the HIV/AIDS community.

AIDS and Wasting

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Conventional thinking is that HIV/AIDS is associated with what has become known as AIDS Wasting Syndrome, characterized by diarrhea, muscle weakness, and severe weight loss. Since the beginning of the epidemic, much of the focus around weight issues and HIV/AIDS has been about wasting and weight loss . . . and for good reason. Unintentional weight loss has been and always will be a clinical consequence of HIV/AIDS. This type of weight loss, associated with malnutrition and wasting, can be as much a predictor of death as opportunistic infections. These conditions do still occur at some point in the progression of the disease to some, or maybe even most, PWAs.

HIV/AIDS and unintentional weight loss have had a long history together. With the inception of AIDS, severe diarrhea, depressed appetite, nausea, and other gastrointestinal complications contributed to incredible weight loss and wasting. In addition, many opportunistic infections were more common then and harder to treat, leading to further weight loss. The primary goal of nutrition intervention in those early days was weight gain in any form and in any way possible. Nutritionists primarily focused on feeding their patients anything that would promote weight gain. Cheese, cream, and milk products full of saturated fats helped boost calorie intake, thereby increasing weight.

With the advent of new drugs, especially protease inhibitors, many people with HIV and AIDS became healthier, or did not become sick in the first place. The incidence of unintentional weight loss decreased. Muscle wasting decreased. Opportunistic infections and deaths decreased as well. While appetite changes and diarrhea continue as side effects of these drugs, overall health has improved. And with this improvement in health came an increase in weight.

AIDS and Weight Gain

But what kind of weight was being gained? Bioelectrical impedance analysis, or BIA, a form of body mass assessment, was until recently very rarely administered, making it hard to say definitively. If this author were to venture a guess, however, it would be that fat rather than muscle was gained. It is much easier to gain fat, especially when weight is increased without the benefits of an exercise program.

So big deal. What difference does it make what kind of weight is gained? Weight is weight, right?

Wrong! Current research indicates that HIV feeds off of muscle and preserves fat stores. It is therefore important to preserve the amount of muscle on your body. In fact, the amount of lean muscle mass on the body is a predictor of long-term survival. The more muscle the better. For example,
a person who weighs 350 pounds is no more protected from infection and death from HIV/AIDS than someone who weighs 150 pounds, if most of the larger person's weight is fat.

Factors in Obesity

It may astonish you to know how easy it is to gain weight. All it takes to gain 10 pounds a year is eating an extra 96 calories per day. That is equivalent to 11/4 apples a day. It is therefore not surprising that statistics show an estimated one in every two adults classified as overweight or obese in the United States, a 25 percent increase over the last three decades. This is worrisome because obesity is a precursor of potentially fatal chronic diseases such as cardiovascular disease, some cancers, and diabetes.

When I speak of obesity I am not talking about lipodystrophy. Some of you may be noticing that you need to loosen your belt a notch because your stomach is expanding. Some women may be experiencing an increase in breast size along with an increase in the size of the back. These are more likely signs of lipodystrophy than of obesity, especially when accompanied by thinning of the arms, legs and facial area. Obesity and lipodystrophy are very different issues.

Given the importance lean muscle mass plays in long-term survival with HIV/AIDS, it is important to understand some of the reasons obesity is on the rise in this community. As stated above, new HIV medications have positively affected health. This is one contributing factor to the rise in obesity; as individuals begin feeling better their appetites increase, and so does food consumption.

Along with this comes a decrease in malabsorption. Foods that once caused problems gastrointestinally become tolerable. A basic premise regarding weight gain centers around calorie consumption. When more calories are consumed than are burned, weight is gained, and most of the excess calories are stored as fat. Since people are malabsorbing less and eating more, they are putting on weight. Furthermore, our nation as a whole has become increasingly sedentary, and this does not exclude those with HIV/AIDS. Again, when calories are not burned, they are stored as fat. It is logical that when individuals eat more and absorb more calories while maintaining the same level of inactivity, fat is gained.

Fear also plays a role. Many of my clients have expressed a certain amount of fear around losing weight. They feel that excess weight will "protect" them from wasting and therefore help lengthen their lives. This is completely false. Muscle is what the virus prefers. It does not matter how much fat is on the body, the virus will attack muscle stores before fat stores. So it makes sense to increase muscle rather than fat. The more muscle your body carries, the more protected your body will be. Fat plays no part in this type of protection.

There are also emotional factors that play a part in this epidemic. Food itself can play a variety of different roles in people's lives. People may use food as a source of comfort; food can help some people feel nurtured, while for others food can be a companion. When food plays this kind of role to a large extent in someone's life, weight gain is likely to occur. In addition, food brings people together; eating is a social activity. Holidays, birthdays, courtship -- all our rituals have food at their centers.

Food is often very much a part of the lives of those in recovery. Many people kick drug and/or alcohol abuse, but the demons that drove those addictions may still be present. Food then becomes the addiction, taking the place of the alcohol or other drugs. I see many former substance abusers who now use food as the drug of choice. Finally, there is also a cultural factor surrounding the issue of obesity. In some cultures, namely African-American and Latino, it is more acceptable than in other cultures to be overweight.

You may be saying to yourself, "I'd rather be fat than wasted." That may be true, but it is important to remember that obesity plays a role in the onset of many chronic, fatal diseases such as cardiovascular disease, diabetes, and some cancers. The more overweight you are, the greater your chances of contracting one of these chronic conditions. In addition, some AIDS medications, namely protease inhibitors, may cause elevated lipid levels and insulin resistance, also linked to these conditions. Thus the new meds combined with increased weight doubles your chances of suffering from these diseases.

Countering Obesity

So, what can you do? The most important thing to remember when losing weight is that it is imperative to monitor what kind of weight is lost. Ideally, you want most of your weight loss to be fat, not muscle, as muscle serves as your protector. This means that you cannot monitor your weight loss via the scale only. Body mass assessments are a crucial tool in weight loss and HIV/AIDS. Bioelectrical impedance analysis is designed to measure fat stores versus muscle stores. When attempting weight loss, monthly or bimonthly BIAs are recommended to ensure that fat is being lost rather than muscle. This should help alleviate some of the fear around losing weight. If proper monitoring is done, wasting should not occur. Many ASOs around New York City, among them GMHC and The Momentum AIDS Project, offer BIAs as a free service for clients. Many M.D.s are now offering this test in their offices as well.

There are many philosophies about weight loss, and I recommend strongly that you consult a Registered Dietitian before embarking on any weight-loss program. Fad diets are abundant. Each decade there is a different craze. Low-fat, high-carbohydrate diets marked the 'eighties, and the 'nineties saw a resurgence of high-protein, low-carbohydrate diets. It is hard to know what to follow and who is preaching the best information.

I believe that the first step to permanent weight loss is to realize that you are not "going on a diet." Rather, you are changing your lifestyle to one that is healthier. Essentially, this is what weight loss provides -- a healthier way of life. You do not have to be at your ideal body weight to be healthy. In fact, it is very possible to be moderately overweight and healthy at the same time. Research has shown that even a small weight loss of ten to fifteen pounds can have a positive effect on your health.

Eating a healthy diet and embracing a regular exercise regimen are definite steps in the right direction. It is important to realize, however, that changing your eating habits is extremely hard. Having realistic expectations and goals is essential to success.

Whole Foods

A good tactic is adopting a "whole foods" approach. Whole foods are those that are closer to nature and less processed than their counterparts. They contain more fiber, vitamins, and minerals to feed your body than highly processed foods. Whole grains are a good example. Try including foods like brown rice, whole wheat or seven-grain breads, and oatmeal and other whole-grain cereals in your diet, rather than highly processed foods such as white rice, sugared cereals, prepared hot cereals, and potato or white bread. Also, try introducing some new grains into your diet. Quinoa, bulgar wheat, and wild rice are a few examples of nutritious grains that can help feed your body and add variety to your diet at the same time.

Fruits and vegetables are another example of whole foods. Not only are they low in fat and calories, they also have immune-boosting powers since they are full of vitamins, minerals, antioxidants, and phytochemicals that help protect your body. They also contain a lot of fiber that can be useful in cardiovascular protection. Five servings per day of fruits and vegetables combined is recommended. You may be thinking that this is a lot of fruits and vegetables to eat in one day, but a "serving" can be one fruit (apple, pear, etc.), a cup of berries, a half-cup of cooked vegetables, or a cup of raw vegetables.

Fats

Another way to change your eating habits is by changing the way you include fat in your diet. Fat is an important part of the diet. It carries certain vitamins through the body, plays a protective role in the body, and is necessary for the health of your hair and skin. Too much fat in the diet, however, is detrimental as it can be immunosuppressive as well as cause weight gain.

The first step to healthy fat consumption is to change the kind of fat you are eating. There are two types of fat, saturated and unsaturated. Saturated fats come from animal sources. Red meat, poultry, dairy products, and eggs are all examples of saturated fats. Saturated fats are linked to increased cardiovascular disease. Choosing lean sources of these foods, especially protein foods like white-meat chicken without the skin, fish, and low-fat milk and yogurt is a good way to start eating healthier. In addition, limiting the amount of cheese you eat and adding beans into your diet as a protein source will help. Try to avoid foods like bacon, hot dogs, sausage, pepperoni, and high-fat luncheon meats such as salami and bologna, all of which contain high amounts of saturated fat.

Unsaturated fats come from plant sources. Avocado, olives, olive and canola oils, nuts, seeds, and nut butters are all sources of unsaturated fats. These are the healthier fats. Choosing fats that are more unsaturated will help maintain your cardiovascular health. Fat is fat, however, and fat in any form is very caloric. So, in addition to changing the type of fat your are consuming, it is important to decrease the total amount of fat in your diet. One sure way of achieving this is to decrease the amount of fried foods in your diet. Start baking, broiling, and grilling your foods rather than frying them. Use products like butter, cream cheese, and oils sparingly. Also, beware of foods that contain hidden fats. A lot of baked goods such as cookies, cakes, muffins (even bran muffins), and crackers contain hidden fats. Moderate your intake of these foods. Remove the skin from chicken before eating it, and trim the fat off of red meats to help reduce the amount of both saturated fat and total fat in your diet.

Another set of foods that contain an incredible amount of fat are fast foods, including Chinese food, burgers, and pizza. Did you know that a Big Mac has 560 calories, 10 grams of saturated fat, and 31 grams of total fat? You can go a long way toward healthier eating by reducing the amount of this type of food in your diet. Try to limit your intake to once a week if possible. Also, when ordering Chinese food, avoid the fried chicken wings, fried dumplings, fried rice, and egg rolls. Instead order chicken, beef, or shrimp with mixed vegetables, steamed dumplings, and brown rice. Another trick is ordering foods steamed with the sauce on the side. which will give you better control of how much fat is in the meal. When eating pizza, have a plain slice rather than one with a high-fat topping such as sausage or pepperoni. If you are eating more than one slice, order one plain slice and one vegetable slice to cut down on calories and fat. Also, try a tuna or turkey sub when eating out at one of the giant sandwich places.

Taking It Off and Keeping It Off

Changing your eating patterns to adopt a whole foods approach and decrease the amount of fat in your diet will only get you so far. In addition to watching what you eat, it is imperative to control the amount of food you consume. Appropriate portion sizes are essential not only to weight loss but to weight maintenance. One easy way to decrease the amount you are eating is to plate your food as you normally do and leave over a part of the meal. This will automatically decrease the amount you are eating. In general, three ounces of meat, a cup of cereal, or an ounce of cheese is considered one serving. Speak with a Registered Dietitian for more detailed information about decreasing portion sizes.

Altering your diet is not the only way to lose weight. Exercise is a great way to increase weight loss and at the same time ensure that you are losing fat and not muscle. There are a few reasons for this. First, exercise will burn a certain amount of calories per day, depending on how long you exercise. Next, the more muscle you have on your body, the more calories you will burn at rest. In other words, exercise can increase your metabolism so you burn calories more efficiently throughout the day, even when you are not exercising.

There are two kinds of exercise, aerobic and anaerobic. Aerobic exercise is more "cardiovascular," which mean it will help strengthen your heart. Examples of aerobic exercises include running, jumping, climbing stairs, and dancing. Anaerobic, or strength training, exercise is any activity that places resistance against the muscle, such as lifting weights, swimming, and yoga. Strength-training exercise is more likely to build lean muscle mass than aerobic exercise. In weight loss, both types of exercise are beneficial -- aerobic exercise to burn calories and strength training to build muscle. Remember, though, exercising is not a license to increase your food intake.

As the face of AIDS is changing, so is the body of the person with HIV. Obesity is a very real, potentially dangerous issue that needs to be addressed. Facing fears around losing weight and learning about the long-term consequences of obesity is essential to the long-term health of people with HIV and AIDS.

Nutrition in Body Positive

The article on these pages is part of Body Positive's ongoing effort to keep its readers informed about nutrition- and food-related issues in HIV and AIDS. It touches upon several topics that have been or will be covered in greater detail in other issues of the magazine. Here's a list:

"Coming Through" by Edwin Krales, M.S., C.D.N. December 1999. Breaking the barriers to good eating.

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